Nasotracheal intubation over a bougie vs. non‐bougie intubation: a prospective randomised, controlled trial in older children and adults using videolaryngoscopy

Abstract

Conventionally, nasotracheal intubation has consisted of blind nasal passage and external manipulation of the tube through the glottis ('conventional technique'), a technique associated with a high incidence of nasal trauma. We evaluated a novel technique for routine asleep (i.e. post-induction) nasotracheal intubation using a bougie ('bougie technique'), which uses a nasopharyngeal airway to guide a paediatric bougie nasotracheally for use as a Seldinger tracheal intubation guide. Two hundred and fifty-seven older children (> 8 years) and adults were randomly assigned to videolaryngoscopy-assisted nasotracheal intubation using either the conventional or the bougie technique. The hypothesis was that the bougie technique would result in less nasopharyngeal trauma. The bougie technique was associated with significantly less nasopharyngeal bleeding than the conventional technique at both 60-90 s (55% vs. 68%; p = 0.033) and 5 min (51% vs. 70%; p = 0.002). The severity of bleeding was also significantly less with the bougie technique, with an OR for active bleeding of 0.42 (95%CI 0.20-0.87; p = 0.020) at 60-90 s and 0.15 (95%CI 0.06-0.37; p < 0.0001) at 5 min. Magill forceps were needed significantly less often with the bougie technique (9% vs. 28%, p = 0.0001) and there was no difference in first attempt and overall success rates between the two techniques (p = 0.133 and p = 0.750, respectively). Not only is nasal intubation over a bougie as successful as the conventional technique, it also significantly decreases both the incidence and severity of nasopharyngeal trauma, as well as the need for the use of Magill forceps.

Comparing bougie‐guided and conventional nasotracheal intubations using videolaryngoscopy

“…As muscle relaxation facilitates establishing such conditions, the earliest administration of a NMB drug following induction of anaesthesia may well be the most effective management strategy in routine clinical practice. Existing evidence including that provided by the investigation of Solt esz et al [1] [1]. The two techniques described -the conventional and the bougie technique -differ in more than just use of the bougie.…”

“…The reason for the high bleeding rate in this study is doubtless multifactorial, but the high proportion of 'learners', with little or no experience with the nasal intubation techniques used in the study, would seem to play a significant part. Comparing bougie-guided and conventional nasotracheal intubations using videolaryngoscopya reply I thank Connolly and Ashcroft for their thoughts on our paper [1], which I am grateful for the opportunity to address below.…”

Comparing bougie‐guided and conventional nasotracheal intubations using videolaryngoscopy

“…In a randomised controlled trial comparing bougie‐guided and conventional nasotracheal intubation using videolaryngoscopy in older children and adults, Abrons et al. showed that a bougie‐guided technique resulted in significantly less nasal trauma and the need to use Magill forceps compared with a conventional technique, but led to prolonged intubation time and no difference in intubation success rate. To differentiate the effect of one factor on primary study end‐points in a randomised controlled trial, however, all of the other factors have to be standardised for avoidance of potential bias.…”

Comparing bougie‐guided and conventional nasotracheal intubations using videolaryngoscopy – a reply

“…I thank Connolly and Ashcroft for their thoughts on our paper , which I am grateful for the opportunity to address below.…”